Effects of the angiotensin II receptor blockers telmisartan versus valsartan in combination with hydrochlorothiazide: a large, confirmatory trial

An update on telmisartan/hydrochlorothiazide combinations for the management of hypertensive patients with additional cardiovascular risk factors

International hypertension guidelines endorse the use of combination therapy to achieve blood pressure control in the majority of patients. Angiotensin AT1 receptor blockers, in combination with diuretics, are among the preferred combinations, with telmisartan plus hydrochlorothiazide (HCTZ) being an effective and well-tolerated combination. This article provides an up-to-date review of the existing data on telmisartan/HCTZ combination for the management of hypertension in patients with additional cardiovascular risk factors, including reports emerging from a number of recent clinical trials and secondary analyses of older trials. The accumulated evidence from clinical trials demonstrates that telmisartan/HCTZ combinations are effective and well tolerated in patients with mild-to-severe hypertension, including subgroups of patients with cardiovascular risk factors such as advanced age, obesity, chronic kidney disease, diabetes mellitus and treatment-resistant hypertension.

The evolving landscape of RAAS inhibition: from ACE inhibitors to ARBs, to DRIs and beyond

Chronic renin-angiotensin-aldosterone system (RAAS) activation has far-reaching effects on cardiometabolic risk and is a substantial contributor to cardiovascular (CV) disease and renal dysfunction. The vascular effects of sustained RAAS activation are associated with hemodynamic imbalances, as well as inflammatory stimulation and prothrombotic processes that lead to fibrosis, endothelial dysfunction and cellular remodeling. RAAS inhibition therapies, which include the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and more recently, direct renin inhibitors, have been used in clinical practice for more than 30 years. Our understanding of how these drugs work, alone and in combination, has contributed to an expanding landscape of treatment options and established RAAS inhibition as essential for reducing the risk of CV and renal disease. This perspective provides a historical overview of how RAAS inhibitors have evolved to their present-day status and will discuss recently discovered functions for components of this complicated and powerful regulatory system.

Telmisartan 80 mg/hydrochlorothiazide 25 mg single-pill combination in the treatment of hypertension

INTRODUCTION

International guidelines emphasize the importance of blood pressure (BP) control to reduce cardiovascular risk. Telmisartan, an angiotensin II receptor blocker, provides large BP reductions and also prevents cardiovascular events in patients at high risk. The thiazide diuretic, hydrochlorothiazide (HCTZ), has a complementary mode of action, and combination with telmisartan is an established and rational treatment option for patients uncontrolled on monotherapy. A single-pill combination (SPC) of telmisartan 80 mg with high-strength HCTZ 25 mg (T80/H25) is widely available.

AREA COVERED

Clinical data on T80/H25 SPC for the management of hypertension was identified via MEDLINE searches. T80/H25 SPC provides greater BP reductions and higher goal achievement rates in patients who cannot achieve BP goal with T80/HCTZ 12.5 mg SPC, and also as initial therapy compared with T80 monotherapy. T80/H25 also reduced BP significantly more than valsartan 160 mg/H25 combination, and demonstrated favorable tolerability in clinical trials.

EXPERT OPINION

Patients with hypertension often do not achieve BP goal, even when treated, leaving them at increased cardiovascular risk. In part this is due to poor adherence, which can be exacerbated by treatment side effects. High BP goal achievement with SPC T80/H25, with maintained tolerability, provides a treatment option for increasing BP control.

Telmisartan or valsartan alone or in combination with hydrochlorothiazide: a review

The aim of this review was to compare telmisartan and valsartan in the treatment of hypertension. PubMed searches were conducted to identify randomized trials (n = 14) comparing the two agents, alone or combined with hydrochlorothiazide. With one exception, all studies with blood pressure reduction as primary endpoint showed significantly greater reductions with telmisartan than with valsartan. Other studies showed that telmisartan was associated with greater improvements in metabolic measures and inflammatory markers than valsartan. These findings suggest that pharmacologic differences between telmisartan and valsartan may translate into clinically relevant differences between the two drugs in the management of hypertension.

Efficacy and tolerability of initial therapy with single-pill combination telmisartan/hydrochlorothiazide 80/25 mg in patients with grade 2 or 3 hypertension: a multinational, randomized, double-blind, active-controlled trial

BACKGROUND

Patients with grade 2 or 3 hypertension may require high-dose combination therapy to achieve blood pressure (BP) targets in a timely manner.

OBJECTIVES

This study compared the effectiveness and tolerability of a single-pill combination (SPC) of telmisartan/hydrochlorothiazide 80/25 mg (T80/H25) with T80 monotherapy.

METHODS

In a Phase IV, multinational, randomized, double-blind, double-dummy, active-controlled, parallel-group trial, 894 patients with mean seated trough cuff systolic BP [SBP] ≥160 mm Hg and diastolic BP [DBP] ≥100 mm Hg were randomly assigned in a 2:1 ratio to receive T40/H12.5 SPC or telmisartan 40 mg monotherapy for 1 week before the dose was uptitrated to T80/H25 SPC or T80, respectively, administered for 6 weeks. The primary efficacy measure was the change from baseline in mean seated cuff trough SBP. Adverse events (AEs) were recorded.

RESULTS

A total of 888 patients received treatment (294 and 594 patients in the T80/H25 and T80 groups, respectively) (mean age, 57.0 years; age ≥65 years, 25.7%; male, 53.8%; white, 68.0%); 61 patients prematurely discontinued. Mean baseline SBP/DBP values were 172.3/104.3 mm Hg (T80/H25) and 173.3/104.5 mm Hg (T80). After 7 weeks, SBP was changed by -37.0 and -28.5 mm Hg in the T80/H25 and T80 groups (P < 0.0001); DBP was changed by -18.6 and -15.4 mm Hg respectively (P < 0.0001). These differences were significant after 2 weeks at the higher dosage (P < 0.0001). BP target (SBP/DBP <140/<90 mm Hg) was achieved in 55.5% and 34.7% of patients in the T80/H25 and T80 groups (P < 0.0001). T80/H25 SPC and T80 had a similar frequency of overall AEs (16.0% vs 17.0%). The prevalences of treatment-related AEs with T80/H25 SPC and T80 were low (4.6% and 2.8%), as were the rates of AEs that led to discontinuation (1.0% and 2.8%).

CONCLUSIONS

In these patients with grade 2 or 3 hypertension, initial therapy with T80/H25 was associated with a significantly greater reduction in mean seated cuff trough SBP compared with T80 alone, as well as with improved hypertension goal attainment rates. Both treatments appeared to be well tolerated.

Telmisartan 80 mg/hydrochlorothiazide 25 mg provides clinically relevant blood pressure reductions across baseline blood pressures

INTRODUCTION

Most patients with hypertension require combination therapy to achieve optimal reduction of blood pressure (BP). The angiotensin II receptor blocker, telmisartan, provides 24-hour BP-lowering efficacy and is proven to prevent cardiovascular morbidity in high-risk patients.

METHODS

Pooled data from seven randomized controlled trials (3,654 patients with stage 1-2 hypertension) were analyzed to investigate the BP-lowering efficacy of telmisartan 40 or 80 mg (T40 or T80) in combination with hydrochlorothiazide 12.5 or 25 mg (H12.5 or H25) when compared with either placebo or telmisartan monotherapy, relative to patients' baseline BP. BP-lowering efficacy was also assessed in subpopulations. The primary endpoint was the change from baseline in seated trough clinic systolic BP (SBP) and diastolic BP (DBP).

RESULTS

In the overall population and across all baseline BP categories, T40/H12.5, T80/H12.5, and T80/H25 resulted in additional BP reductions to those provided by telmisartan monotherapy. In patients with baseline SBP≥170 mmHg, T80/H25 effected a mean SBP change of -39.2 mmHg compared with changes of -25.5 mmHg and -8.3 mmHg observed with T80 and placebo treatment, respectively. Mean DBP changes were -20.4 mmHg T80/H25, -12.2 T80 and -5.9 placebo in patients with baseline DBP≥105 mmHg. T80/H25 also resulted in larger BP reductions than telmisartan monotherapy in black patients with hypertension, irrespective of baseline BP. In patients with hypertension with type 2 diabetes and in patients with moderate or severe renal impairment, both T80/H12.5 and T80/H25 were more effective than monotherapy in reducing BP in all baseline BP categories.

CONCLUSION

Combination treatment of telmisartan and hydrochlorothiazide results in large and clinically relevant BP reductions additional to those provided by monotherapy.

Effects of Telmisartan with Hydrochlorothiazide versus Valsartan with Hydrochlorothiazide in Patients with Moderate-to-Severe Hypertension

Combination therapy is recommended for patients with blood pressure (BP) significantly above goal by recent consensus guidelines around the globe. The use of angiotensin II receptor blockers (ARBs) alone or in combination with a thiazide diuretic is a preferred treatment strategy due to both efficacy and safety considerations. However, there are few data known about the benefits of ARB-diuretic combination therapy in patients with moderate-to-severe hypertension. We performed a subanalysis from two large clinical trials that compared the antihypertensive effects of telmisartan 80 mg versus valsartan 160 mg, both combined with hydrochlorothiazide (HCTZ) 25 mg in a subpopulation of 725 patients with moderate-to-severe hypertension (systolic BP SBP ≥ 160 mm Hg). Treatment with telmisartan-HCTZ induced significantly greater reductions in BP (−31.1/−18.3 mm Hg) than valsartan-HCTZ (−28.4/−16.3 mm Hg; SBP P = 0.0265, diastolic BP P = 0.0041). More patients receiving the telmisartan combination achieved a BP goal < 140/90 mm Hg than those receiving valsartan-HCTZ. There were similar safety and tolerability data for the two active treatment groups. These findings support the use of longer-acting ARBs combined with higher doses of thiazide diuretic to improve BP control in patients with moderate-to-severe hypertension.

Effects of telmisartan and amlodipine in combination on ambulatory blood pressure in stages 1-2 hypertension

BACKGROUND

Evaluation of combination therapy with antihypertensive agents by clinic blood pressure (BP) measurements may yield results that differ from out-of-office BP readings. This is of clinical relevance because out-of-office BP values are of prognostic importance. We studied the effects of combining telmisartan and amlodipine on ambulatory BP in patients with stages 1-2 hypertension.

METHODS

We conducted an 8-week, placebo-controlled, double-blind, 4x4 factorial design trial in which 562 patients with clinic diastolic BP at least 95 and 119 mmHg or less were randomized to receive telmisartan (0, 20, 40, or 80 mg) and/or amlodipine (0, 2.5, 5, or 10 mg). Ambulatory BP monitoring was performed at baseline and after 8 weeks of treatment; the end points of interest were the changes from baseline in 24-h systolic and diastolic BP. Secondary end points included the proportion of responders (> or =10 mmHg BP reduction from baseline and/or <130/80 mean 24-h BP) and controlled patients (<130/80 mmHg mean 24-h BP).

RESULTS

Combination therapies of telmisartan and amlodipine lowered 24-h BP to a larger extent than the corresponding monotherapies at all doses. Mean reductions from baseline in 24-h BP for the combination of the highest doses of telmisartan (80 mg) and amlodipine (10 mg) were -22.4/-14.6 versus -11.9/-6.9 mmHg for amlodipine (10 mg) and -11.0/-6.9 mmHg for telmisartan (80 mg) (P<0.0001 for each comparison). In addition, BP response and control rates (24-h BP <130/80 mmHg) were significantly higher with the combination therapy versus the monotherapy groups.

CONCLUSION

These findings show that telmisartan and amlodipine in combination provide substantial 24-h BP efficacy that is superior to either monotherapy in patients with stages 1 and 2 hypertension.

Telmisartan and hydrochlorothiazide combination therapy for the treatment of hypertension

BACKGROUND

Control of elevated blood pressure has been shown to reduce the risk of cardiovascular events. The angiotensin II receptor blocker (ARB), telmisartan, has been shown to provide effective 24-hour blood pressure control. Additional antihypertensive efficacy can be achieved by combining telmisartan with the thiazide diuretic hydrochlorothiazide (HCTZ).

OBJECTIVE

To review the clinical data in combination therapy with telmisartan and HCTZ.

METHODS

Search of Medline and Embase for published clinical studies using the keywords telmisartan and HCTZ.

FINDINGS

The telmisartan/HCTZ combination provides significant reductions in blood pressure, effective 24-hour blood pressure control and is well-tolerated. Blood pressure reductions with this combination are greater than those achieved with either drug alone, and in comparative studies telmisartan/HCTZ is more effective than other ARB/HCTZ combinations. However, it should be noted that some of the combinations assessed used doses of the drugs that were commercially available at the time of the trial and not higher doses that have been shown to have greater antihypertensive efficacy.

CONCLUSION

The combination of telmisartan/HCTZ is an effective and well-tolerated treatment option for patients with hypertension.

New standards in hypertension and cardiovascular risk management: focus on telmisartan

Blockade of the renin–angiotensin system is an important approach in managing high blood pressure, and has increasingly been shown to affect cardiovascular disease processes mediated by angiotensin II throughout the cardiovascular and renal continua. Telmisartan is an angiotensin II receptor blocker (ARB) displaying unique pharmacologic properties, including a longer half life than any other ARB, that result in large and sustained reductions of blood pressure. In patients with mild-to-moderate hypertension, telmisartan has proved superior to other antihypertensive agents (valsartan, losartan, ramipril, perindopril, and atenolol) in controlling blood pressure particularly towards the end of the dosing interval. There is also clinical evidence that telmisartan reduces left ventricular hypertrophy, reduces arterial stiffness and the recurrence of atrial fibrillation, and confers renoprotection. The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET^®) study has demonstrated that telmisartan has similar cardiovascular protective effects to ramipril in a large, high-risk patient population but was better tolerated. The powerful and sustained blood pressure control apparent in clinical trials, together with cardiovascular protection and tolerability demonstrated in ONTARGET^® means that telmisartan may be a preferred option for patients with hypertension.

A randomized, comparative, multicentric evaluation of atenolol/amlodipine combination with atenolol alone in essential hypertensive patients

As there is a strong, positive, and continuous correlation between blood pressure and risk of cardiovascular diseases; improved control of blood pressure is necessary to produce maximum reduction in clinical cardiovascular endpoints. The primary objective was to demonstrate that atenolol/amlodipine combination therapy is superior to atenolol monotherapy with respect to mean fall in systolic blood pressure and diastolic blood pressure. The secondary objective was to compare the response rate and to evaluate the tolerability of study medications. This randomized, comparative, multicentric, 12-week study consisted of screening visit followed by baseline visit 48-hours postscreening. All enrolled patients received 7-day placebo washout. Eligible patients were randomized to receive either atenolol 25 mg/amlodipine 2.5 mg or atenolol 25 mg alone. Nonresponders after 4 weeks of therapy were escalated to atenolol 50 mg/amlodipine 5 mg or atenolol 50 mg, respectively. Out of 190 enrolled patients (94: combination group; 96: monotherapy group), 174 patients (84: combination therapy, 90: monotherapy) completed the study. After 4 weeks of therapy, low-dose combination group was superior to low-dose monotherapy with respect to mean fall in SBP (P = 0.008) and DBP (P = 0.021) and response rate (P = 0.012). Also high-dose combination therapy was superior to high-dose monotherapy with respect to mean SBP (P = 0.001), DBP (P = 0.011), and response rate (P = 0.035) at the end of 12 weeks of therapy. At the end of therapy, significantly more number of patients from combination group achieved normalization of BP (SBP < 120 mmHg and DBP < 80 mmHg) (P = 0.009). Thus, once daily treatment with atenolol/amlodipine fixed-dose combination offers superior antihypertensive efficacy over atenolol monotherapy in patients with mild-to-moderate essential hypertension.

Impact of angiotensin receptor blockade in combination with hydrochlorothiazide 25 mg in 2121 patients with stage 1-2 hypertension

The antihypertensive effects of telmisartan 80 mg versus valsartan 160 mg, both combined with hydrochlorothiazide (HCTZ) 25 mg, were assessed in a pooled analysis from two large trials with identical study designs in patients with stage 1-2 hypertension. The trials were double-blind with a 4:4:1 randomization scheme to compare once-daily telmisartan 80 mg and HCTZ 25 mg versus once-daily valsartan 160 mg and HCTZ 25 mg versus once-daily placebo on reductions in clinic blood pressure (BP). The primary end point was changes from baseline in BP at the end of 8 weeks. In total, 2121 patients were randomized (telmisartan-HCTZ, 942, valsartan-HCTZ, 952, and placebo, 227) and had baseline seated BPs of 154/102 and 155/102 mm Hg in the two studies, respectively. Changes from baseline in BP after administration of telmisartan-HCTZ (-24.5/-18.0 mm Hg) were significantly greater than for both placebo (-4.1/-6.5 mm Hg) and valsartan-HCTZ (-22.3/-16.8 mm Hg) (versus placebo, P<0.0001 for systolic and diastolic BP; versus valsartan-HCTZ, P=0.0004 for systolic BP and P=0.0019 for diastolic BP). Adverse event rates were higher in the placebo group than in the active treatment groups (placebo, 41%, telmisartan-HCTZ, 30%, and valsartan-HCTZ, 30%, P<0.05). These data confirm that telmisartan-HCTZ at doses of 80/25 mg lowered systolic and diastolic BP to a greater extent than valsartan-HCTZ at doses of 160/25 mg in stage 1-2 hypertension. The magnitude of the BP-lowering effect provides support for the use of angiotensin receptor blockers with higher doses of a thiazide diuretic (25 mg) to improve hypertension control.

Telmisartan/Hydrochlorothiazide: a review of its use as fixed-dose combinations in essential hypertension

Fixed-dose combinations of telmisartan and hydrochlorothiazide (HCTZ) [Micardis Plus, Micardis HCT, PritorPlus] are available in many countries for the treatment of patients with essential hypertension. Combining the angiotensin II receptor antagonist (angiotensin II receptor blocker [ARB]) telmisartan with the thiazide diuretic HCTZ provides antihypertensive therapy with complementary mechanisms of action. In the US and EU, telmisartan/HCTZ is approved for patients whose hypertension is not adequately controlled with telmisartan monotherapy; US labelling for the fixed-dose combination also includes inadequate control of blood pressure (BP) with HCTZ monotherapy.The antihypertensive efficacy of once-daily telmisartan/HCTZ has been demonstrated in several large, randomized trials in patients with stages 1 and 2 hypertension. The addition of HCTZ to telmisartan achieved significant reductions in BP in nonresponders to telmisartan monotherapy, and the antihypertensive efficacy of telmisartan/HCTZ was similar to or significantly greater than that of various comparator agents. Moreover, in studies that used ambulatory BP monitoring, telmisartan/HCTZ provided consistent 24-hour BP reductions throughout morning, daytime and night-time periods. The BP-lowering efficacy over the entire 24-hour dose administration interval is consistent with the pharmacokinetic profile of telmisartan, which has the longest elimination half-life among currently available ARBs and a unique chemical structure. Adverse events with telmisartan/HCTZ in clinical trials were typically mild and transient, and no unexpected events occurred that had not been previously reported with either telmisartan or HCTZ. Extensive tolerability data are available for telmisartan, in particular from the ONTARGET study, the largest clinical outcomes trial with an ARB. As such, fixed-dose combinations of telmisartan/HCTZ provide an effective, rational and generally well tolerated treatment option for the management of patients with hypertension.